1. Harvath, Theresa A. PhD, RN, CNS


When theory and practice clash.


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Felicia Walters, age 85, was admitted to a nursing home for rehabilitation after falling at home. (Identifying details have been changed.) Ms. Walters had been lying on the floor for a day and a half when her neighbor found her. Shortly after admission, our interdisciplinary team recognized that dementia was preventing her from reaping the benefits of physical and occupational therapy. The team held a family conference to discuss discharge plans. Ms. Walters's daughter and two neighbors agreed that nursing home placement was a foregone conclusion. She was no longer safe living alone.


During the family conference, Ms. Walters's nurse turned to her and asked whether she wanted to say anything. She lifted her head and said, loudly and clearly, "I'd rather spend three days on the floor in my own home than three years in any nursing home!!" She bowed her head again as we sat in stunned silence.

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Her daughter asked whether it was possible to send her home. Her neighbors said that they could check on her once or twice a day. The social worker suggested a home health care aide to help with meals and bathing. We put together a plan for Ms. Walters that included an emergency call button and home modifications. Then the physical therapist voiced our collective concern: What would be the repercussions for both the patient and the care team?


Nurses learn early on about Maslow's hierarchy of needs. At the base of the pyramid are physiological needs. Next are safety, love and belonging, and esteem, with self-actualization at the apex. Maslow developed the hierarchy as a way to conceptualize the motivations behind human behavior. Nurses have used this hierarchy to guide the prioritization of patient care needs. As a gerontologic clinical nurse specialist, I have had problems with this. In the care of older adults, patients' need for autonomy (considered part of self-actualization on the pyramid) can collide with their need for safety. For example, as Sharp and Bryant reported in Seminars in Speech and Language in 2003, older patients with dysphagia sometimes choose textured foods, despite the risk of aspiration, because food plays such a central role in their lives. Similarly, Yardley and colleagues in Health Education Research in 2006 found that older adults at risk for falling resist home modifications (such as removing throw rugs) because they fear that such precautions will breed dependence. When the needs for safety and autonomy clash, older adults often choose autonomy over safety.


Ms. Walters stated her choice succinctly, despite cognitive impairment. In the end, we honored her request and sent her home with as much support as possible. We documented our decision, concluding that although we weren't ignoring her risk for injury from falling, we saw that the threat to the quality of her life was of greater concern.


Perhaps nursing's reliance on Maslow's theory in prioritizing older patients' needs is not prudent. And perhaps the theory has even been misinterpreted. Patient autonomy is so important that patients can voice their need for it, even through the darkening cloud of dementia. Rather than assuming that patients' needs come in a preordained order, nurses should instead plan care according to what's important to each individual patient.